I.

The eye The eye (L., oculus; Gk, ophthalmos) lies in the cavity of the orbit and measures approximately 24 mm in diameter. The midpoints of the two pupils lie about 60 mm apart. If the eye is too short in relation to the lens, near objects are focused behind the retina (hypermetropia: farsightedness or longsightedness). In contrast, if the eye is too long in relation to the lens, distant objects are focused in front of the retina (myopia: nearsightedness or shortsightedness) The retina, which may be regarded as an extension of the wall of the brain, develops from neural ectoderm, whereas the lens and the anterior epithelium of the cornea are derived from somatic ectoderm. Neural crest and mesoderm also participate in ocular development. Tunics of eye The eyeball (globe or bulb) has three concentric coverings (1) an external, fibrous tunic comprising the cornea and sclera; (2) a middle, vascular tunic comprising the iris, ciliary body, and choroid; and (3) an internal, nervous tunic, or retina. External fibrous tunic The cornea is the anterior, transparent part of the eye, and it forms about one-sixth of the circumference of the fibrous coat. Most of the refraction by the eye takes place not in the lens but at the surface of the cornea. The cornea is continuous with the conjunctiva and the junctional region is known as the limbus. The cornea is supplied by the ophthalmic nerve (from the fifth cranial nerve) by means of its ciliary branches. The eyelids close on stimulation of the cornea. The cornea is avascular and consists of five layers histologically: a largely collagenous substantia propria enclosed by anterior and posterior epithelia and limiting laminae. When the cornea does not conform to a sphere but is more curved in one axis than in another, the condition is termed astigmatism. Irritation of the eye, e.g., from a foreign body, causes hyperemia of the conjunctiva, which may also result from infection or allergic conditions (conjunctivitis). The posterior conjunctival arteries (from the palpebral arcades become dilated and give a brick-red color to the conjunctiva. Inflammation of the cornea (keratitis) or of the iris and ciliary body (iridocyclitis) causes dilation of the anterior ciliary arteries (from muscular branches of the ophthalmic, resulting in a rose-pink band of "ciliary injection". These vessels, unlike those of the conjunctiva, do not move when the conjunctiva is moved. The sclera is the posterior, opaque part of the external tunic. Its anterior part can be seen through the conjunctiva as "the white of the eye". The sclera consists of fibrous tissue, and it receives the tendons of the muscles of the eyeball. Posteriorly, the fibers of the optic nerve pierce the sclera through a weak plate termed the lamina cribrosa. External to the sclera, the eyeball is enveloped by a thin fascial sheath (so-called Tenon's capsule) that extends from the optic nerve to the sclerocorneal junction. The sheath separates the globe from the orbital fat and acts as a socket in which the eye moves as in a ball-and-socket joint. It blends with the sheaths of the muscles of the globe. Hormonal disturbances (especially hyperthyroidism) may result in swelling of the orbital fat and extra-ocular muscles, causing protrusion of the eyes (exophthalmos). An important, circular canal termed the scleral venous sinus (known to ophthalmologists as the canal of Schlemm) is situated at the sclerocorneal junction, anterior to a projection termed the scleral spur. The aqueous humor, formed by the ciliary processes, filters through intercellular channels leading from the anterior chamber to the venous sinus and drains by means of aqueous veins into scleral plexuses. The iridocorneal angle (between the iris and the cornea), also known as the angle of the anterior chamber or as the filtration angle, is very important physiologically (for the circulation of aqueous humor) and pathologically (in glaucoma). Middle vascular tunic The middle tunic, frequently termed the uvea, comprises the choroid, the ciliary body, and the iris, from posterior to anterior (a) The choroid is a vascular, highly pigmented coat that lines most of the sclera. (b) The ciliary body connects the choroid with the iris. The part near the choroid is a smooth ciliary ring (pars plana), whereas that near the iris is a ridged crown (pars plicata). The ciliary body contains the ciliary muscle and the ciliary processes, and is lined by the ciliary part of the retina. The ciliary muscle comprises two main sets of smooth-muscle fibers: (1) longitudinal fibers connect the sclera (anterior) to the choroid (posterior), and (2) oblique fibers enter the base of the ciliary processes. The ciliary muscle is supplied by parasympathetic fibers by way of the ciliary nerves. On contraction, the ciliary body moves anteriorward. This decreases the tension on the fibers of the ciliary zonule so that the central part of the lens assumes a more globular, curved shapeto permit the eye to focus on near objects, a process known as accommodation. The ciliary processes, about 70 in number, are arranged in a circle posterior to the iris. They are the site of secretion of the aqueous humor. The iris is a circular, pigmented diaphragm that lies anteiro to the lens in a more or less coronal plane. It is anchored peripherally to the ciliary body, whereas its central border is free and bounds the aperture known as the pupil. The iris divides the space between the cornea and the lens into two chambers. The anterior chamber is bounded largely by the cornea and iris. It communicates through the pupil with the posterior chamber, which is bounded by the iris, ciliary processes and zonule, and lens. Both chambers are filled with aqueous humor. The anterior surface of the iris presents a fringe known as the collarette. The pattern of radial striations in the iris is unique from one individual to another and, like fingerprints, can be used for identification. The stroma of the iris normally contains melanin pigment, and the amount, which is low in blue eyes, is considerable in brown irides. A congenital, radial defect of the iris is termed a coloboma. The sphincter pupillae is situated in the posterior part of the iris, near the pupil, and consists of smooth muscle. The sphincter pupillae is supplied by parasympathetic fibers by way of the short ciliary nerves, and its contraction results in constriction of the pupil (miosis). The iris contracts reflexly when light reaches the retina (the light reflex) and when focusing on a near object (part of the accommodation reaction). A drop of an atropine-like drug placed on the eye annuls the action of the ciliary muscle and the sphincter pupillae, both of which are under parasympathetic control. The resultant dilatation of the pupil (caused by overaction of the dilator) is of use in the examination of the eye. The dilator pupillae consists of smooth muscle anterior to the pigmented epithelium on the posterior aspect of the iris, which constitutes the iridial part of the retina. The dilator pupillae is supplied by sympathetic fibers, and its contraction results in dilatation of the pupil (mydriasis). This sympathetic innervation arises as preganglionic nerve fibers leaving the spinal cord in the upper 4 thoracic ventral roots. White rami communicans transmit the sympathetics to the gangliated chain and the preganglionic fibers enter and ascend the cervical sympathetic chain. These sympathetic preganglionic fibers synapse in the

superior cervical ganglion. Postganglionic sympathetic nerve fibers originating from this ganglion join the carotid artery and comprise a dense plexus of nerves surrounding the branches of this artery. The nerve fibers follow the internal carotid and ophthalmic arteries to reach the eye. Damage to sympathetic nerve fibers anywhere along this pathway can result in Horner syndrome, with a small (meiotic) pupil and slight drooping of the upper eyelid due to paralysis of the superior tarsal muscle. The autonomic innervation. The autonomic innervation of the eye may be summarized in the following manner. Parasympathetic (synapses in ciliary ganglion) - sphincter pupillae, ciliary muscle.

Sympathetic (synapses in superior cervical ganglion) - dilator pupillae, orbitalis (smooth muscle of inferior orbital fissure), superior tarsal muscle (smooth muscle in eyelid), blood vessels of choroid and retina.

Internal nervous tunic (retina) The retina contains special receptors on which is projected an inverted image of objects seen. Because of the partial crossing of nerve fibers at the optic chiasma, the retina of each eye is connected with both right and left visual areas of the forebrain. The retina is shaped like a sphere that has had its anterior segment removed, leaving an irregular margin termed the ora serrata. The sensory elements of the retina end at the ora, but a pigmented continuation lines the ciliary body and the posterior part of the iris as the ciliary and iridial parts of the retina. In other words, the ciliary body and the posterior iris are lined by retinal epithelium (a double layer), which, however, is insensitive to light. Basically, the retina comprises two main strata: (1) an external, pigmented stratum derived from the external lamina of the embryonic optic cup and (2) an internal, transparent, nervous stratum derived from the inverted lamina of the optic cup. A separation of the nervous from the pigmented stratum may occur along a plane that represents the residual cavity of the embryonic optic vesicle. This is commonly called detachment of the retina, and it may arise from an accumulation of fluid caused by a hole or a tear in the retina. Methods for repair include the use of a cryoprobe or a laser to produce an adhesive scar between these layers, preventing further separation. The macula is a small, yellowish area of the retina on the temporal side of the optic disc . It contains a pit, the fovea centralis, which in turn presents a depression, the foveola. The foveola contains only cone photoreceptor cells and functions in detailed color vision, when an object is looked at directly. The entering optic nerve fibers form the optic disc. This is the "blind spot", insensitive to light because photoreceptor cells are absent there. It is situated nasal to the posterior pole of the eye and to the fovea centralis. Normally the optic disc is flat and does not form a papilla, but, near its center, where vessels enter and leave, a variable depression, the "physiological cup", is present. The optic nerve is surrounded by meningeal sheaths and the subarachnoid space, so that an abnormal rise in intracranial pressure (e.g., caused by an intracranial tumor or hemorrhage) also places pressure on the optic nerve. This may result in a hydrostatic phenomenon that can be detected by ophthalmoscopy as a blurring of the margins of the optic disc ("choked disc" or papilledema) and loss of the physiological cup. Compression of the central vein of the retina, which courses inside of the optic nerve, may be a factor in the production of this swelling of the optic nerve head. The retina is nourished externally by the choroid and internally by the central artery of the retina, a branch of the ophthalmic artery. The central artery travels in the optic nerve and divides at the optic disc. The branches of the central artery of the retina are endarteries, so that an occlusion causes loss of vision in the corresponding part of the visual field. The fundus oculi is the posterior part of the interior of the eye as seen on ophthalmoscopy. Dioptric media of eye The refractive apparatus of the eye are collectively termed the dioptric media and consist of the cornea (which contributes most of the optical power), aqueous humor, lens, and vitreous body. The aqueous humor, formed by the ciliary processes, circulates through the posterior chamber, pupil, anterior chamber, iridocorneal angle, trabecular meshwork, and scleral venous sinus, thereby reaching the ciliary veins. The intra-ocular pressure depends chiefly on the ease of drainage of the aqueous humor. The scleral venous sinus (known to ophthalmologists as the canal of Schlemm) is an annular, endothelial channel at the sclerocorneal junction. Glaucoma is a disorder generally (although not always) characterized by increased intra-ocular pressure. In the angle-closure (narrowangle) type the iris blocks either the trabecular meshwork or the pupil, thereby hindering drainage of aqueous humor to the scleral venous sinus. In the open-angle type no grossly visible obstruction is seen, but abnormalities within the trabecular meshwork, for example, may be present. As a result of pressure, excavation (cupping) of the optic disc may occur, as well as a diminution of the visual field. In one type of operation, a small segment of the iris is excised (peripheral iridectomy), thereby re-establishing adequate humoral communication between the posterior and anterior chambers. The lens, biconvex and 1 cm in diameter, is covered by a capsule and consists of cellular lens fibers. The lens capsule is anchored to the ciliary body by its suspensory ligaments, or ciliary zonule (figs. 46-4 and 46-5). When distant objects are being looked at, the ciliary muscle is relaxed and elastic fibers in the choroid pull on the ciliary body, which, in turn, keeps the zonular fibers and also the lens capsule under tension. This pul results in flattening of the lens (fig. 46-8D). The lens, in addition to becoming increasingly yellow with age, also becomes harder and less elastic, as a result of which the power of accommodation is lessened (presbyopia) and convex spectacles may be required for reading. An opacity of the lens is termed a cataract. It is commonly age-related and it may interfere with vision. The lens can be removed by either intracapsular extraction (removal of the entire lens and its capsule) or extracapsular extraction (retaining the posterior part of the capsule and the zonule to support a plastic lens implanted in the posterior chamber). "Couching" for cataract, i.e., a mere displacement of the lens by a needle introduced into the eye, is one of the oldest of surgical operations (it was performed in Roman times). The vitreous body is a transparent, gelatinous mass that fills the eyeball posterior to the lens. The movement of specks in the vitreous body is sometimes seen as muscae volitantes (L., flitting flies), or "floaters". General sensory innervation and blood supply of eye Sensory fibers from the cornea and uvea reach the nasociliary nerve (of the ophthalmic nerve) by way of the short and long ciliary nerves. The eye receives its blood supply (fig. 46-10) from the ophthalmic artery by way of the central artery of the retina, short and long posterior ciliary arteries, and the anterior ciliary arteries (from muscular branches of the ophthalmic artery). Most of the veins from the eye accompany the arteries and drain into the cavernous sinus by way of the ophthalmic veins.

The pharynx and larynx

Pharynx The word throat is used for the parts of the neck anterior to the vertebral column, especially the pharynx and the larynx. The pharynx is the part of the digestive system situated posterior to the nasal and oral cavities and posterior to the larynx. It is therefore divisible into nasal, oral, and laryngeal parts: the

(1) nasopharynx, (2) oropharynx, and (3) laryngopharynx. The pharynx extends from the base of the skull down to the inferior border of the cricoid cartilage (around the C6 vertebral level), where it becomes continuous with the esophagus.

Its superior aspect is related to the sphenoid and occipital bones and the posterior aspect to the prevertebral fascia and muscles as well as the upper six cervical vertebrae.

The pharynx a fibromuscular tube lined by mucous membrane. The pharynx is the common channel for deglutition (swallowing) and respiration, and the food and air pathways cross each other

in the pharynx. In the anesthetized patient, the passage of air through the pharynx is facilitated by extension of the neck.

Subdivisions Nasopharynx. The nasopharynx, at least in its anterior part, may be regarded as the posterior portion of the nasal cavity, with which it has a common function as part of the respiratory system. The nasopharynx communicates with the oropharynx through the pharyngeal isthmus, which is bounded by the soft palate, the palatopharyngeal arches, and the posterior wall of the pharynx. The isthmus is closed by muscular action during swallowing. The choanae are the junction between nasopharynx and the nasal cavity proper. A mass of lymphoid tissue, the (naso)pharyngeal tonsil is embedded in the mucous membrane of the posterior wall of the nasopharynx. Enlarged (naso)pharyngeal tonsils are termed "adenoids" and may cause respiratory obstruction. Higher up, a minute pharyngeal hypophysis (resembling the adenohypophysis) may be found. Each lateral wall of the nasopharynx has the pharyngeal opening of the auditory tube, located about 1 to 1.5 cm (1) inferior to the roof of the pharynx, (2) anterior to the posterior wall of the pharynx, (3) superior to the level of the palate, and (4) posterior to the inferior nasal concha and the nasal septum. The auditory tube can be catheterized through a nostril. The opening is limited on the superior side by a tubal elevation (tubal torus), from which mucosal folds descend to the palate and side wall of the pharynx. The part of the pharyngeal cavity posterior to the tubal elevation is termed the pharyngeal recess. Nearby lymphoid tissue is referred to as the tubal tonsil. The auditory tube is pharyngotympanic; i.e., it connects the nasopharynx to the tympanic cavity. Hence, infections may spread along this route. The tube equalizes the pressure of the external air and that in the tympanic cavity. The auditory tube, about 3 to 4 cm in length, extends posteriorly, laterally, and superiorly. It consists of (1) a cartilaginous part, the anteromedial two thirds, which is a diverticulum of the pharynx, and (2) an osseous part, the posterolateral third, which is an anteromedial prolongation of the tympanic cavity. The cartilaginous part lies on the inferior aspect of the skull, in a groove between the greater wing of the sphenoid bone and the petrous part of the temporal bone. The cartilaginous part of the auditory tube remains closed except on swallowing or yawning, when its opening prevents excessive pressure in the middle ear. The osseous part of the tube is within the petrous part of the temporal bone. Oropharynx. The oropharynx extends inferiorward from the soft palate to the superior border of the epiglottis. It communicates anteriorly with the oral cavity by the faucial (oropharyngeal) isthmus, which is bounded superiorly by the soft palate, laterally by the palatoglossal arches, and inferiorly by the tongue. This area is characterized by a lymphatic ring composed of the nasopharyngeal, tubal, palatine, and lingual tonsils.

The mucous membrane of the epiglottis is reflected onto the base of the tongue and onto the lateral wall of the pharynx. The space on each side of the median glosso-epiglottic fold is termed the epiglottic vallecula. Each lateral wall of the oropharynx has the diverging palatoglossal and palatopharyngeal arches, which are produced by the similarly named muscles and are often called the anterior and posterior pillars of the fauces, respectively. The triangular recess (tonsillar fossa) between the two arches lodges the palatine tonsil, which is often referred to as merely "the tonsil" . (A tonsil is a mass of lympoid tissue containing reaction or germinal centers and related to an epithelial surface in the pharynx.) The medial surface of the tonsil usually has an intratonsillar cleft (commonly but inaccurately called the "supratonsillar fossa") and a number of crypts. The lateral surface is covered by a fibrous capsule and is related to fascia, the paratonsillar vein (the chief source of hemorrhage after tonsillectomy), and pharyngeal musculature. The tonsil is supplied by the tonsillar branch of the facial artery, and it drains into the facial vein. Involution of the tonsil begins at puberty. Laryngopharynx. The laryngopharynx extends from the superior border of the epiglottis to the inferior border of the cricoid cartilage, where it becomes continuous with the esophagus. Its anterior aspect has the inlet of the larynx and the posterior aspects of the arytenoid and cricoid cartilages. The piriform recess, in which foreign bodies may become lodged, is the part of the cavity of the laryngopharynx situated on each side of the inlet of the larynx.

Larynx The larynx is the organ that connects the lower part of the pharynx with the trachea.

It serves (1) as a valve to guard the air passages, especially during swallowing, (2) for the maintenance of a patent airway, and (3) for vocalization. The anterior aspect of the larynx is quite superficial and the posterior aspect of the larynx is related to the laryngopharynx, the prevertebral fascia and muscles, and to the bodies of cervical vertebrae 3 to 6.

Laterally, the larynx is related to the carotid sheath, infrahyoid muscles, sternomastoid muscle, and the thyroid gland. The larynx is elevated (particularly by the palatopharyngeus muscle) during extension of the head and during deglutition.

Cartilages

Figure 53-8. The structures in or near the anterior median line of the neck: (1) symphysis menti, (2) diaphragma oris (mylohyoid muscles) crossed by the digastric muscles, (3) hyoid bone, (4) median thyrohyoid ligament, (5) laryngeal prominence of the thyroid cartilage (overlying the glottis), (6) cricothyroid ligament, (7) arch of the cricoid cartilage, (8) cricotracheal ligament, (9) trachea and isthmus of the thyroid gland, (10) inferior thyroid veins forming a plexus, (11) jugular arch uniting the right and left jugular veins, (12) thymus (chiefly in childhood) and occasionally part of the brachiocephalic trunk or of the left brachiocephalic vein, and (13) jugular notch of the manubrium sterni. The infrahyoid muscles are not shown here.

Figure 53-9. The larynx. A, B, and C, Anterior, posterior, and right lateral views of cartilages. D, Right anterolateral aspect, showing the planes of section of figure 53-10. Note the thyroid and cricoid cartilages and the hyoid bone and epiglottic cartilage in A to D and the arytenoid cartilages in B

Figure 53-10. A, Coronal and, B, median views of the larynx.

Figure 53-14. The rima glottidis (in yellow) and the vocal ligaments in (A) phonation, (B) forced inspiration, and (C) quiet respiration. Note the rotation and lateral sliding of the arytenoid cartilages and the different shapes of the glottis. D, Muscles of the larynx seen from above. The white arrows Land P show the direction of action of the lateral and posterior crico-arytenoid muscles, respectively. The black arrows show the direction of action of the transverse arytenoid muscle. M, muscular process of the arytenoid cartilage; V, vocal process of the arytenoid cartilage. It should be noticed that the apex of the A formed by the vocal ligaments is located anteriorly.

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